Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 000787 | MO |
Y | 222Z00000X | Podiatrist | 000787 | MO |
NPI | 1023151685 |
---|---|
Provider Name | Dr. Dan D Park |
First Address | Springfield, MO 65801-2580 |
Second Address | Springfield, MO 65807-7304 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2007 |
Last Update Date | 09/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
118724 | MO BLUE SHIELD (01) | MO |
309802700 | (05) | MO |
81727 | ARK BLUE SHIELD (01) | AR |
U02176 | (02) |